# NTSB WPR20CA066: Piper PA 23, N1428P, Helena, MT, January 8, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: January 8, 2020, 16:00 local (23:00 UTC) - Place: Helena, MT - Coordinates: 46.606945, -111.983055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.6069&lon=-111.9831&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 16, 2020 - Report: Approved by Office Director - NTSB office: Western Pacific Region - NTSB case key (mKey): 100820 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20CA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100820/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100820 - Page: https://openairdocs.org/ntsb/WPR20CA066 ## Probable cause The pilot's improper decision to attempt an off-airport departure from rough terrain without inspecting the takeoff area, which resulted in a collision with a shallow rut during takeoff and the nose landing gear collapsing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102302), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=7102302), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7102302), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102302), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=7102302), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) - [Takeoff: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7102302), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The flight instructor reported that, during an instructional flight in a twin-engine airplane, which included feathering and unfeathering the left engine in flight, the left engine would not restart. The airplane was unable to maintain altitude and reach the destination airport, so he landed the airplane on a field about 1/2 mile from the airport. After the instructor successfully started the engine on the ground, the student pilot walked back to the airport, while the instructor decided to attempt an off-airport departure from the frozen ground with 4-inch-tall alfalfa stubble. He chose a takeoff path that didn't have any visible obstructions, which he estimated would allow for a 3,000-ft-long ground roll. He then taxied to the edge of the field, held the brakes, applied full power to the engines, and released the brakes, and the airplane began to move. About 700 ft into the ground roll, the airplane impacted a shallow rut from an irrigation pivot, and the nose landing gear collapsed, which resulted in substantial damage to the forward fuselage. The pilot reported that his decision to take off from the field was poor because he made it without first walking the takeoff terrain. ## Factual narrative The pilot reported that during an instructional flight in a twin-engine airplane he made a successful landing to a stubble field approximately one half mile from their destination airport following a failed mid-air engine restart. After successfully starting the engine on the ground, the student walked back to the airport, while the pilot decided to attempt an off-airport departure from the frozen ground with 4 inch tall alfalfa stubble. He selected a takeoff path that didn't contain any visible obstructions and that he estimated would allow for a 3,000 ft ground roll. The pilot taxied to the edge of the field, held the brakes, applied full power to the engines, released the brakes and the airplane began to move. Approximately 700 ft into the ground roll, the airplane impacted a shallow rut from an irrigation pivot and the nose landing gear collapsed, which resulted in substantial damage to the forward fuselage. In a subsequent interview, the pilot commented that his decision to depart from the field was poor as he made the decision to execute the takeoff without first walking the takeoff terrain. ## Aircraft - Registration: [N1428P](https://openairdocs.org/deregistered/N1428P-2020-06-04), registration cancelled 2020-06-04, S/N 23-484, built 1956 (OpenAirDocs) - Reported make and model: Piper PA 23 (Undesignat) - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-484 - Year built: 1956 - Airframe hours: 5051 - Engines: Lycoming O-320 150 horsepower reciprocating; Lycoming O-320 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 16, 2019, 12 hours before - Departed: HLN, Helena, MT - Destination: HLN, Helena, MT - Airport: HLN, Helena Rgnl ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review August 31, 2018; seat: left; restraint: lap only; flight hours: 8,174 total, 1,874 in this make and model, 7,939 as pilot in command, 294 in the last 90 days, 98 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 7 knots - Visibility: 10 statute miles - Temperature: 39 °F, dew point 21 °F - Altimeter: 29.54 inHg ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20200108003339A](https://openairdocs.org/incident/20200108003339A), Jan 8, 2020: Piper PA-23, Helena, MT, Substantial damage. Departed with student on an instructional flight to the local practice area. They conducted a shutdown of the left engine and were unable to conduct an air… ## Docket (5 files) The files NTSB released with the investigation on March 4, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100820. 3.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481018&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Weather Reports and Records (item 2, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481019&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Pilot's Statement (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481020&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Record of Conversation (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481021&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Accident Photographs (item 5, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481022&FileExtension=.PDF&FileName=Accident%20Photographs-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.